Monday, July 15, 2013

Summer immersion started of great. I am matched with Dr.
Mark Souwiedane, who is the director of Pediatric Neurosurgery at Weill Cornell
and has appointments at MSKCC in Pediatric Neuro-Oncology. It was great finding
out I was matched with a neurosurgeon. I was happy as it was a bit of a
departure from what I work with in lab, a chance to learn something new. But
when I found out the immersion was going to with Pediatric-Oncology, I was a
bit ambivalent...those cancer kids advertisement automatically came to mind.
However, after this week it seems that the cases we saw were mostly treatable.

From what I can tell, Dr. Souweidane spends his time split
between the Craniofacial Clinic, Brain & Spine Center at Cornell-NYPH, the
Operating room, MSKCC and his overseeing his lab. To handle all this he has his
patient schedule mostly managed by his RN Coleen, and Charlotte. He has one
Neurosurgery Fellow, Dr. Konstantine Margetis, who works primarily with him.

The first day was entirely a clinic day at the Brain and
Spine center. As patients came in one by one the whole group started going
thought notes, MRI’s, and CT scans. The usual logistics were Charlotte or Coleen
had the original conversation/counsel after the patient has been referred to
Dr. Souweidane. Then after a quick history and reason for visit refresher, the
images are analyzed be the fellow plus resident and visiting med student. After
a neuro work up/physical tests, the case is presented to Dr. Souweidane with
all the finding and possible diagnosis/prognosis; where he revises all the
images, makes a his conclusions, goes in with everyone and gives his medical
opinion.

Day 1 (Brain and Spine center) we saw a total of 12 cases.
Ranging from Craniosynostosis, where the infants cranial sutures fuse early lading
to cranial deformity; to shunt revisions and Chiari malformation, where the
cerebellum herniates from the foramen magnum.

Day 2 (OR day) where I observed two ventricular shunts being
implanted into premature babies, that developed hydrocephalus. The way the head
had swollen up, it seemed unreal. After the shunt was implanted to drain right
under the scalp. After the shunt was implanted, the head radically shrunk down,
and the babies’ head is turned to the other side every 3 hours, so they don’t
form any deformities. I also observed a
shunt revision, where the shunt was not draining the ventricles, and the
implanted was cleared with suction.

Day 3 (a lab day) Where I went to Dr. Souweidanes’ lab group
meeting talked about lab project possibilities. Saw how they are working on
their CED (Convection Enhanced Delivery) clinical study.

Day 4 (Cranial Facial Clinic Day) consulted 3 surgery cases
dealing with Craniosynostosis, and talked about the possible clinical projects
I could contribute on. After going to a Fellows case conference during lunch,
we all went to Brain and Spine center. In the clinic a patient was consulted on
a Chiari case, and since the surgery will be schedules for expedience, I might
be able to observe this procedure.

Day 5 (OR day) Dr. Soueweidane and Dr. Grienfield lead the
weekly morning Residents meeting, where they grill them on procedures and
diagnostics. After that I was able to observe an endoscopic cyst removal. Then
a cranioplasty of young girl with a synthetic machined bone that has been
modeled from the patients CT scan. This case was super long, as there was soo
much scar tissue, making in extremely hard to expand the scalp over the
implant.

So needless to say, the first immersion week was pretty
jam-packed. Hopefully, it will stay like this and I will share with you the
highlights from now on.

Thursday, July 11, 2013

Though this week was a short one, I still
managed to see and learn a lot.The highlight of the week was when I received my clinical research
project.After weeks of feeling guilty
and spinning my wheels as I sought in vain for a reasonable research project, I
now have a specific task to accomplish: writing a literature review about
xanthogranulomas versus craniopharyngiomas and other similar tumors.Though this project has no relation to my PhD
thesis or research interests, I am grateful for it, and it will be useful to
practice writing a literature review.Additionally, the knowledge I gain will be extremely beneficial the next
time I attend a seminar on distinguishing factors in rare brain tumors.

This week, I attended rounds in the OB
ward.It was nice to be in a part of
the hospital where most patients were there for a positive reason.Listening to the attending and residents on
the round, I quickly realized that doing a bit of preliminary research on
common abbreviations would have been helpful. During my time spent shadowing Dr.
Schwartz, one surgery stood out in particular because it emphasized the
importance of robust engineering. The
surgery used a transphenoidal approach to remove a craniopharyngioma from a
young patient and was a team effort between Dr. Schwartz and otolaryngologist
Dr. Anand. The surgery was complex and
lasted over eight hours. Near the start
of the surgery, Dr. Schwartz noticed that the tip of one of the scalpel-like
devices had broken off. He was not sure
if it had been like that before, or if it had broken off inside of the boy’s
head. It was necessary to have an x-ray
taken to ensure that the piece was not lodged somewhere inside and in need of
retrieval. The x-ray ended up not taking
place until the end of the surgery.
Fortunately, no metal shard was detected, meaning that the tool must
have been broken from the beginning.
Several hours later, when Dr. Schwartz had reached the tumor
and was slowly removing chunks of it, the vacuum that provided suction to his
tools stopped working. This meant that
he could not see his workspace as well because it was filled with fluid and he
had to progress at a much slower rate.
Meanwhile, nurses were trying to figure out why the pump was
malfunctioning and calling the company to troubleshoot. Eventually, they were able to retrieve a new
pump from a different room, but it took a lot longer than I anticipated. Once the new pump had been set up, the surgery
was able to proceed as planned, and the remaining portion of the procedure went
smoothly.

Wednesday, July 3, 2013

Week three has been a smorgasboard of
shadowing experiences…resulting in further affirmation that entering a PhD program
was the right choice for me.Monday, I
shadowed plastic surgeon Dr. Spector during his office hours.It was quite the contrast to my previous
clinic experience with neurosurgeon Dr. Schwartz.MRI scans are the stars of neurosurgery
clinics.The patient and his/her entourage sit fully
clothed in ordinary chairs; the obligate examination bed just an obstacle to
weave around when entering the room.Much
of the conversation involves comparing various anatomies of the brain on the
charts and demonstrating how they have changed.The plastic surgery office hours are much more intimate.Body parts are palpated and
photographed.Botox is injected, sutures
are removed.The atmosphere is a bit
flashier, a bit less somber.

Wednesday was
another change of pace as I shadowed members of the pediatric intensive care
unit (PICU) on their morning rounds.Surprisingly, the PICU cares for children who are only a few months old
all the way up to age 22.This was my
first time going on rounds and I wasn’t quite sure what to expect.The attending and additional rounding personnel
spoke softly in low voices when discussing patients, making it difficult to
hear the discussion through the ambient white noises filling the room. I was extremely grateful to one of the
physician assistants for answering my perpetual questions and summarizing
discussions for me.One sad case
demonstrated how fixing one problem can result in another being created.A toddler with leukemia had received a bone
marrow transplant.Unfortunately, graft
vs. host disease had developed and a small hole had formed in his
intestine.Fortunately, the hole had
fixed itself, but not before bacteria had been released.A healthy baby might have been able to fight
it off, but he was on drugs to suppress his immune system because of the
transplant.Thus, he needed strong
antibiotics.All of the drugs then led
to him having renal failure and kidney problems.Despite these problems, the baby was in
fairly stable condition when I saw him.I want to continue to follow this case and
hopefully see the baby make it out of the hospital.As we shuffled from room to room, a large cart
with a computer containing electronic medical records was dragged along as
well.While electronic records have many
benefits, I witnessed the hassle they can present.Residents scrolled through long lists of
possible medical procedures, only to find the specific one they wanted to
record wasn’t there.The software seemed
like it had a ways to go before it would make their lives easier.

Thursday and
Friday were ER days.The first day I
spent in the ‘A bay,’ which is where patients with the most immediate problems
are triaged.The A bay contains the A1
bed, which is where patients go when they are pulled off the ambulance and in
need of intense medical assistance.The
day started off with a meeting that went over some cases and also contained a
teaching component.The topic was on
acetaminophen (Tylenol) overdoses.Once
of the reasons that acetaminophen overdose is so deadly is because there is an
intermediate phase where the patient feels fine, yet his/her liver is rapidly
being destroyed.One of the patients in
the PICU was there due to a Tylenol OD, so it was interesting to learn more
about the biochemistry behind the treatment.I spent the remainder of the day following around a resident as he
tended to several patients.The whole ER
was crammed with patients; many were without a room and lay in beds lining the
hallway.The C bay was even crazier than
the A bay (partly because it was a Friday evening).The patients in C were more elderly and
tended to have chronic medical problems in addition to the acute one that
brought them into the ER.When making
rounds, one of the attendings commented on how tough an elderly lady was;
despite taking a bad fall in the night, the patient had waited until the next
afternoon to come in.“Tough?” the
patient snorted, “Chicken is more like it—I’m scared of the ER.” Personally, I
was rather inclined to agree with the patient.Incredible as the medicine is performed in the ER is, I prefer the
calmer neurosurgery clinic and operating room and am looking forward to
returning there next week.

Wednesday, June 26, 2013

After seeing Dr. Schwartz at work in the clinic and operating room, I was curious to learn more about his lab. Last week, I visited Dr. Schwartz’s lab and learned a bit about the research; however, only one of the members, Dr. Hongtao Ma, was there. This week, I got to hear from Dr. Mingrui Zhao as well, who coincidentally had been up visiting Ithaca the previous week. Despite being a research lab, the Schwartz Lab felt much less like the home-away-from-home I was anticipating. Instead of having hoods and cabinets filled with chemicals, optical and electrical equipment crammed the room. Soldering irons sat out on benches next to assorted pliers, wires, and glass probes. It was not just the equipment and research that was different; the entire lab personnel structure was different from any lab I’d worked in previously. As far as I could tell, the lab consisted of Dr. Schwartz (who has an MD, but not a PhD), two assistant professors, Dr. Ma and Dr. Zhao, (who hold PhDs, but not MDs) and an assortment of summer students (such as myself). It was interesting that despite being assistant professors, Dr. Ma and Dr. Zhao still spent a lot of time in the lab. To me, one of the least appealing aspects of becoming a professor would be spending all day writing grants and going to meetings, instead of actually performing lab research, so it is good to know that post-doc-like professorships exist. That being said, I do not think I would enjoy working in a hospital if I were not a doctor. It is almost a bit like a caste system, with glamorous, life-saving MDs on top and mousy academics tucked away in their labs underneath. Having no MD (nor burning desire to get one) makes me feel quite the outsider.

Dr. Ma and Dr. Zhao study epilepsy by performing craniotomies on mice and recording the hemodynamic, metabolic, and electrical changes that occur immediately before, during, and after focal seizures. By identifying the changes that occur before a seizure takes place, they hope to be able to predict, and eventually prevent, seizures. Because there are only 5-ish weeks left in the program, and I have no knowledge or training in this field, it will be challenging to set up a complete research project. However, I’m always up for a challenge, and I look forward to further shadowing Dr. Ma and Dr. Zhao.

My clinic experience was similar to last week. There were many success stories of patients who initially had tumors who were now healthy and tumor free, as well as sad stories of tumors returned and surgical difficulties. One case that stood out involved a young woman who had been involved in a car accident. She had severely damaged one part of her skull, so a custom skull prosthetic had been used to repair that site. The surgery had gone well, but the skin over the prosthetic had failed to heal; instead, it became necrotic, forming an eschar and losing all the hair on it. This was extremely unusual and Dr. Schwartz postulated that it was possible that the skin had been stitched too tightly over the prosthetic, thus preventing sufficient blood flow to the tissue.

One of my highlights this week was going to MRI training. Though I had seen MRIs in pictures and pictures from MRIs, I had never operated one. Thanks to fellow summer student, Amanda, prior summer student, Mitch, and phantom-extraordinaire, MR Plastic, I was able to perform an MRI. Directly seeing the effects of varying parameters, such as repetition and echo times, helped me to better understand how MRIs work. Now, I just have to work on learning to better interpret the images produced!